Provider Demographics
NPI:1902010382
Name:GOODALL, SANDRA ANN (LLP)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:ANN
Last Name:GOODALL
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21880 DAISY LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3913
Mailing Address - Country:US
Mailing Address - Phone:248-462-5267
Mailing Address - Fax:
Practice Address - Street 1:22255 GREENFIELD RD STE 300
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3729
Practice Address - Country:US
Practice Address - Phone:248-849-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008152103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist